III.Initiatives to improve societal health
Creating the right environment and supporting behaviors that lead to a healthy life will deliver healthier students to schools, healthier workers to employers and businesses, and a healthier population to the healthcare system.
How can we enhance this positive cycle? Addressing both individual and population health and working at both levels is essential.
Reduction of the chronic disease burden needs coordinated and mutually reinforcing actions: epidemiology and surveillance to monitor trends and track progress, policy and environmental approaches to promote health and support healthy behaviors, healthcare interventions to improve the effective delivery and use of preventive and other high-value clinical services, and links between community programs and clinical services to improve and sustain the management of chronic conditions.
Who is responsible for driving these changes?
To answer we must consider who benefits from a healthy population: individuals, schools, companies and employers, the healthcare system in many cases, and the government.
The most obvious place to start are government policies. For example, in Sweden (see the case example below) the government has set a broad range of objectives in their public health policy that are required to create the conditions for better health on equal terms for the entire population.
Source: Linell et al. 2013
Case: Sweden’s approach to public health
In autumn 2000, a national public health committee, commissioned by the Swedish government, submitted proposals for national objectives for public health. In April 2003, the Swedish parliament decided on a sector-independent public health policy, which at the time was unique internationally and based on an overarching national aim and eleven objective domains. When the public health policy was formulated, it was based on the factors that affect health, or so-called determinants, instead of diseases and health problems. Following up on the factors that affect health instead of diseases allowed for faster indication of how the situation is changing, which in turn can expedite political decisions.
The overarching aim of public health is to create the societal conditions for good health on equal terms for the entire population.
The 11 objective aims
- Participation and influence in society
- Economic and social prerequisites
- Conditions during childhood and adolescence
- Health in working life
- Environments and products
- Health-promoting health services
- Protection against communicable diseases
- Sexuality and reproductive health
- Physical activity
- Eating habits and food
- Alcohol, illicit drugs, doping, tobacco, and gambling
Case: Chile’s Law of Food Labeling and Advertising on sugar-sweetened beverage purchases
The government of Chile was grappling with one of the world’s highest obesity rates: three-quarters of Chilean adults and more than half of Chilean children were overweight or obese, and health officials warned that the medical costs of obesity could consume 4% of the nation’s healthcare spending by 2030, up from 2.4% in 2016.
As a first step to tackle the issue, a 2014 measure raised the tax on sugary beverages to 18% from 13%. Then, in 2016, Chile implemented the Law of Food Labeling and Advertising, a set of policies designed to prevent further increases in obesity prevalence by subjecting foods and beverages high in energy, sugar, sodium, and saturated fat content to marketing restrictions, banning their sales in schools, and implementing the first national mandatory front-of-package (FOP) warning-label system. Mandatory package redesigns erased cartoons like Tony the Tiger from sugary cereal boxes, and television advertising restrictions banished adverts for unhealthy products from the airwaves between 6 a.m. and 10 p.m.
According to the latest evaluation of the policy, the purchase volume of high-in beverages decreased by 22.8 mL per capita per day (23.7%) after the regulation was implemented. The drop in sugary beverage consumption occurred both among the highly educated and those without a high school degree, although the reductions were somewhat greater among individuals who attended college. This observed decrease was greater than purchase changes that have been observed following implementation of single, standalone policies in Latin America, such as a sugar-sweetened beverage tax.
Legislators there are now considering what may be called a “mega tax” on processed foods — the frozen pizza, instant noodles, and fast-food meals that are responsible for two-thirds of all calories consumed by children.
Future research will be needed to understand to what degree these changes are attributable to product reformulation and/or to changes in consumer behavior, as well as the impact of these regulations on dietary intake and health-related outcomes.
The role of private and civil society sectors should not be overlooked as they potentially also have a larger role to play in enhancing population health.
Achieving the vision and societal benefits of value-based healthcare requires collaboration between all healthcare stakeholders: payers, providers, manufacturers, NGOs, and patients. For that reason, new financial mechanisms such as risk-benefit partnerships are needed to encourage stakeholders to cross silos and improve the health and wellbeing of populations. In addition, financial challenges have put pressure on governments throughout the world to find alternative ways to fund non-acute but important wellbeing and health services – such as prevention and better management of chronic illnesses.
Impact investing is an emerging model of risk-benefit agreement. It has been recognized as a possible solution to increase outcome-oriented collaboration. To meet rising service demand in the context of highly constrained public resources, risk-benefit sharing through impact investing allows governments and other beneficiaries to experiment with novel services that solve complex social or health issues. Impact investing has been mainly utilized to target vulnerable populations (for example people with long-term health conditions) that have difficulties in receiving sufficient support from existing services.
How impact investing works
Impact investing is a partnership that is established between investors, service delivery organizations, NGOs, and government (for example hospital systems and cities). The aim is to tackle a specific societal challenge – such as a health issue – through a multi-agency approach. In particular, impact investing represents a promising approach to encourage additional investments in early, evidence-based interventions to prevent future problems and reduce the need for more costly services such as secondary care.
In contrast to reactive services that respond to crises, impact investing models channel funding into early interventions that prevent future problems and generate savings. Impact investment utilizes private capital to enable the upfront services required for achieving health outcomes. If the pre-financed solution or service achieves the agreed-upon health outcomes, the beneficiary (for example, the government) pays the investors against a pre-agreed scale. As such, the risk of service failure is almost completely transferred away from the government to impact investors, whose financial return is based on the achievement of outcomes.
The results so far
Based on the experience so far, impact investing has enabled greater flexibility in terms of both overall care management approaches and service delivery in ways that might have been difficult or even impossible under current reimbursement and service commissioning models. Impact investing funded programs enable spot-purchasing of items for beneficiaries (such as health technology, precise therapies, and other relevant services or products) as well as more personalized services in response to varying client needs and preferences. One additional advantage is scalability. Programs financed by impact investing instruments are potentially easier to scale and implement across regions and even internationally. Replicable contractual schemes such as health impact bonds are suitable and easily adaptable for different types of health systems, no matter if they are insurance based or universal systems.
If optimally implemented, impact investing offers policy makers and public decision makers a ‘win-win-win’ scenario: better health and social outcomes, public sector savings, service innovations, and a financial return to impact-driven investors. In this sense, the overall benefits of a program funded by impact investing models (such as a health impact bond) can go beyond cost savings. As this approach can accelerate service innovations, benefits could include regional vitality, increased tax income, and other externalities such as social capital.
Due to the potential of broadly shared value, impact investing instruments – such as health or social impact bonds – have become one of the most promising financial schemes used by governments for welfare interventions that promote cost-effective models for disease prevention and reduce taxpayer expenditure.
It’s important to remember that impact investing is still in its early days. This means there is a lack of awareness of impact investing and its potential benefits among commissioners, investors, and service providers. One additional difficulty is caused by siloed public services. As impact investing funded projects are typically quite holistic by their nature and deliver benefits across multiple public sector areas, more examples are needed as to how commissioners can collaborate across budgeting silos. Future research is still needed to analyze aspects such as information asymmetries between the involved parties and the entire set of risks emerging from these innovative contractual schemes. These examples of key challenges emphasize the importance of shared learning and open cross-sector collaboration around the topic in the future.
Health impact bonds
Health impact bonds (HIBs) have recently become part of the public services landscape. In a health impact bond contract, public sector commissioners partner with private or third sector social investors to provide up-front funding for interventions that tackle complex health issues. Under these arrangements, non-government investors cover the upfront costs necessary to set up the interventions implemented by service providers, while the government commissioner commits to pay a return on investment if pre-defined desired outcomes are reached. These outcomes may be, for example, lower health-related costs in a population and a higher quality of life, which leads to healthier populations. From a service provider and solution ecosystem perspective, health impact bonds provide a mechanism to enable prevention and wellness initiatives, while simultaneously earning a return on the money committed.
The main players involved in a health impact bond are:
- A funder, who puts up the initial capital to fund the intervention
- An operator, who performs the intervention and in many cases runs the service ecosystem
- A payer, usually government, who makes payments to the investor based on the impact achieved
Impact bonds in the health field generally have three potential goals:
- Preventing illness, which reduces direct and indirect costs
- Reducing the indirect cost (social/economic) of illness
- Finding a cure for disease
Most contracted impact bonds to date fall into the first category.
Sign up to solve exercises:
After completing Chapter 3, you should be able to:
- Understand that societal value-based healthcare means a healthy population that needs less healthcare
- Explain why it’s worth investing in health and the key ways we can measure population health
- Explain some of the initiatives currently in use to improve societal health